Provider Demographics
NPI:1063195592
Name:ANDERSON, MARK D (LPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 CHERITON CT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7951
Mailing Address - Country:US
Mailing Address - Phone:908-962-5753
Mailing Address - Fax:
Practice Address - Street 1:2430 CHERITON CT
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7951
Practice Address - Country:US
Practice Address - Phone:908-962-7532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC013180101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor